Inspection Reports for Hope Center for Hiv and Nursing Care
1401 University Avenue, Bronx, NY, 10452
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 16, 2025, found multiple deficiencies across areas including environment, care planning, respiratory care, staffing, medication management, food safety, and infection control. Earlier inspections showed a pattern of similar issues with care planning, environment, supervision, and staffing, as well as isolated findings related to resident rights and reporting requirements. Complaint investigations were mostly unsubstantiated except for a substantiated case in October 2024 involving improper use of physical restraints during a haircut, which was corrected. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s deficiencies have persisted over time with recurring themes, indicating ongoing challenges rather than clear improvement.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
19.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
282% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Deficiencies: 13
Date: May 16, 2025
Visit Reason
The inspection was a Recertification Survey conducted from 05/12/2025 to 05/16/2025 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including maintaining a safe and homelike environment, developing and implementing comprehensive care plans, providing appropriate respiratory care, ensuring sufficient nursing staff, maintaining accurate pharmaceutical records, proper medication storage, food safety, and infection prevention and control practices.
Deficiencies (13)
Failed to maintain a safe, clean, comfortable, and homelike environment including sticky floors, leaking shower, dirty bedside tables, and missing window treatments.
Failed to develop comprehensive person-centered care plans with measurable objectives and time frames for residents' medical, nursing, mental, and psychosocial needs.
Did not ensure interdisciplinary team reviewed and revised residents' comprehensive care plans after each assessment.
Did not provide treatment and care according to orders and professional standards, including failure to implement incentive spirometry due to lack of equipment.
Did not provide treatment and services to maintain or improve range of motion for a resident with limited ROM; splints were not applied as ordered.
Failed to provide safe and appropriate respiratory care, including oxygen administered at incorrect flow rate and lack of incentive spirometer use.
Did not ensure sufficient nursing staff were available to meet residents' needs; documented ongoing staffing shortages and resident complaints.
Failed to maintain accurate drug records and reconcile controlled substances; missing nurse signatures and discrepancies in narcotic counts.
Did not ensure drug regimen reviews by consultant pharmacist were reviewed and acted upon timely by attending physicians.
Failed to store drugs and biologicals in locked compartments; medication storage rooms contained unlocked medications, food, and used intravenous bags.
Did not procure, store, prepare, and serve food in accordance with professional standards; outdated food and unsafe food temperatures observed.
Infection prevention and control practices were not maintained; previously used intravenous solution bag was stored improperly.
Infection Preventionist did not participate in Quality Assessment and Assurance committee meetings as required.
Report Facts
Dronabinol capsules: 16
Missing nurse signatures: 24
Staffing ratio: 1
Staffing ratio: 2
Staffing ratio: 3
Staffing ratio: 2
Food temperature: 120
Food temperature: 123
Food temperature: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse Supervisor | Named in findings related to respiratory care and medication administration. |
| Registered Nurse #2 | Nursing Supervisor | Named in findings related to medication storage and narcotic count discrepancies. |
| Licensed Practical Nurse #1 | Interviewed regarding care plan responsibilities. | |
| Licensed Practical Nurse #2 | Interviewed regarding oxygen administration and medication counts. | |
| Certified Nursing Assistant #1 | Interviewed regarding splint application and staffing. | |
| Certified Nursing Assistant #3 | Interviewed regarding staffing shortages and resident care. | |
| Director of Nursing | Interviewed regarding care plans, staffing, medication administration, and infection control. | |
| Primary Care Physician | Interviewed regarding medication orders and consultant pharmacist recommendations. | |
| Pharmacy Consultant | Interviewed regarding medication regimen reviews. | |
| Administrative Assistant | Interviewed regarding ordering of incentive spirometers. | |
| Housekeeping Director | Interviewed regarding cleaning schedules and equipment availability. | |
| Housekeeper #1 | Interviewed regarding cleaning and equipment availability. | |
| Occupational Therapist | Interviewed regarding splint orders and resident contracture. | |
| Registered Nurse #3 | Interviewed regarding medication storage practices. | |
| Registered Nurse #4 | Interviewed regarding staffing and medication administration. | |
| Medical Director | Interviewed regarding medication regimen review process. | |
| Infection Preventionist | Staff Educator | Interviewed regarding infection control practices and committee participation. |
| Food Services Director | Interviewed regarding food preparation and temperature control. | |
| Corporate Dietary Director | Interviewed regarding food temperature measurement. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 22
Date: May 16, 2025
Visit Reason
Inspection identified 13 standard health citations and 9 life safety code citations, all Level 1 or 2 severity, with no actual harm but potential for minor harm. All deficiencies were corrected by July 3, 2025.
Findings
Inspection identified 13 standard health citations and 9 life safety code citations, all Level 1 or 2 severity, with no actual harm but potential for minor harm. All deficiencies were corrected by July 3, 2025.
Deficiencies (22)
Care plan timing and revision
Develop/implement comprehensive care plan
Drug regimen review, report irregular, act on
Food procurement,store/prepare/serve-sanitary
Increase/prevent decrease in rom/mobility
Infection prevention & control
Label/store drugs and biologicals
Pharmacy srvcs/procedures/pharmacist/records
Qaa committee
Quality of care
Respiratory/tracheostomy care and suctioning
Safe/clean/comfortable/homelike environment
Sufficient nursing staff
Cooking facilities
Develop ep plan, review and update annually
Doors with self-closing devices
Electrical equipment - power cords and extens
Emergency lighting
Fire alarm system - testing and maintenance
Hazardous areas - enclosure
Means of egress - general
Portable fire extinguishers
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Oct 22, 2024
Visit Reason
The inspection was conducted as an abbreviated survey to investigate allegations related to a resident's rights being violated during a haircut procedure and the use of physical restraints without medical justification.
Complaint Details
The complaint investigation was triggered by reports that Resident #1 was forcibly restrained and had their hair cut against their will on 01/25/2024. The facility's investigation confirmed the incident, noting no physical harm but violation of resident rights and improper restraint use.
Findings
The facility failed to ensure that Resident #1 was able to exercise their rights, as staff held the resident down against their will to cut their hair. The facility also failed to prevent the use of unnecessary physical restraints, as Resident #1 was physically restrained without documented medical necessity or alternatives attempted. The investigation concluded that the haircut was performed against the resident's will, though no physical harm occurred.
Deficiencies (2)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights, evidenced by staff holding Resident #1 down against their will to cut their hair.
Failure to prevent the use of unnecessary physical restraints; Resident #1 was held down without documented medical necessity or alternatives prior to restraint use during a haircut.
Report Facts
Residents sampled: 4
Brief Interview of Mental Status score: 6
Date of incident: Jan 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Instructed by Director of Social Work to hold Resident #1 during haircut | |
| Home Health Aide #1 | Assisted in holding Resident #1 during haircut | |
| Director of Social Work | Instructed staff to hold Resident #1 and was present during haircut | |
| Recreational Aide #1 | Reported Resident #1 refused haircut and became combative | |
| Recreational Supervisor #1 | Received report from Recreational Aide and informed Director of Nursing | |
| Barber #1 | Licensed Barber | Performed haircut on Resident #1; reported resident consent initially but became combative |
| Director of Nursing | Became aware of incident and confirmed staff held Resident #1 against will | |
| Registered Nursing Supervisor #1 | Reported not being informed of resident refusal during haircut |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Oct 22, 2024
Visit Reason
Inspection identified 2 standard health citations related to resident rights and freedom from chemical restraints, both Level 2 severity and corrected by December 5, 2024.
Findings
Inspection identified 2 standard health citations related to resident rights and freedom from chemical restraints, both Level 2 severity and corrected by December 5, 2024.
Deficiencies (2)
Resident rights/exercise of rights
Right to be free from chemical restraints
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Dec 22, 2023
Visit Reason
The inspection was a standard recertification survey conducted from 12/18/2023 to 12/22/2023 to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in multiple areas including maintaining a safe, clean, and homelike environment with issues such as chipped paint, broken bathroom equipment, and shabby furnishings; inadequate discharge planning for Resident #33; inadequate supervision to prevent accidents and altercations; unsafe food temperatures during meal service; improper dishwashing and pot washing procedures; improper garbage disposal; failure to provide required rehabilitative services for Resident #55; damaged nursing station desk; and unsecured handrails in Unit 2.
Deficiencies (9)
Residents did not have a homelike environment due to multiple issues with paint chips, scratches, broken bathroom equipment, and shabby furnishings in communal areas.
Discharge planning process did not address Resident #33's discharge goals and needs; discharge care plan was not reviewed or revised to reflect resident's desires.
Inadequate supervision to prevent accidents and hazards, including Resident #264 eloping by climbing fence and Resident #33 being unsupervised leading to altercation.
Foods were not served at safe and appetizing temperatures; hot foods below ideal temperature during meal service on Units 3 and 4.
Dishwashing machine did not maintain appropriate wash and rinse temperatures; pot washing procedure did not follow proper sanitation standards.
Garbage compactor outside was not properly covered or closed, exposing garbage and allowing pest harborage.
Resident #55 was not evaluated or screened for physical therapy services despite physician order.
Unit 2 nursing station had mismatched paint and damaged desk with chipped and missing veneer and scuff marks.
Handrails in Unit 2 hallway were not firmly secured; two sections were loose and not fully connected.
Report Facts
Working hours per shift: 40
Floor buffer broken duration: 3
Dish machine final rinse temperature: 153
Dish machine wash cycle temperature: 147
Sanitizer strength: 500
Hot food temperature on Unit 3: 119
Hot food temperature on Unit 4: 124
Lasagna temperature in kitchen steam table: 156.4
Chicken temperature in kitchen steam table: 163
Lasagna temperature on Unit 3 lunch tray: 158
Tossed salad temperature on Unit 3 lunch tray: 50
Lasagna temperature on Unit 4 lunch tray: 129
Fence height: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #3 | Registered Nurse | Interviewed about shift working hours and maintenance work order process. |
| Other #14 | Housekeeping worker | Interviewed about cleaning routines and pest problem on Unit 4. |
| Other #15 | Housekeeping worker | Interviewed about cleaning routines on Unit 4. |
| Other #16 | Maintenance worker | Interviewed about maintenance routines and repair request process. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about reporting broken equipment and maintenance communication. |
| Other #3 | Facilities Director | Interviewed about maintenance staffing, painting, and facility repairs. |
| Housekeeper #1 | Housekeeper | Interviewed about cleaning duties and floor buffer status. |
| Director of Social Work | Director of Social Work | Unavailable for interview; related to discharge planning deficiency. |
| Associate Administrator | Associate Administrator | Interviewed about Resident #33's discharge planning. |
| Director of Nursing Service | Director of Nursing Service | Interviewed about Resident #33's discharge barriers. |
| Receptionist #1 | Receptionist | Interviewed about backyard door security and surveillance. |
| Recreation Leader/Smoke Monitor | Recreation Leader/Smoke Monitor | Interviewed about supervision during smoke breaks and Resident #264 elopement. |
| Director of Recreation | Director of Recreation | Interviewed about smoke monitor duties and supervision. |
| Substance Abuse Counselor #1 | Substance Abuse Counselor | Interviewed about altercation between Resident #33 and Resident #214. |
| Registered Nurse #1 | Registered Nurse | Interviewed about response to altercation and supervision in dining room. |
| Director of Food Service | Director of Food Service | Interviewed about food temperatures, dish machine repairs, and garbage compactor. |
| Dietary Worker #1 | Dietary Worker | Observed and interviewed about pot washing procedures. |
| Physical Therapist #1 | Physical Therapist | Interviewed about PT screening and treatment schedule. |
| Director of Rehab | Director of Rehab | Interviewed about missed PT screening for Resident #55. |
| Maintenance Worker #1 | Maintenance Worker | Interviewed about maintenance rounds and repair requests. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 22, 2023
Visit Reason
The inspection was a recertification survey conducted from 12/18/2023 to 12/22/2023 to assess compliance with regulatory requirements for the nursing home facility.
Findings
The facility was found deficient in discharge planning, supervision to prevent accidents and altercations, and maintaining a safe and comfortable environment. Specific issues included failure to update discharge plans reflecting resident goals, inadequate supervision leading to elopement and resident altercations, and physical damage to the Unit 2 nursing station.
Deficiencies (4)
Failure to ensure a discharge planning process addressing each resident's discharge goals and needs, specifically for Resident #33 whose discharge plan was not reviewed or revised to reflect their wishes.
Inadequate supervision to prevent accidents or hazards, including Resident #264 eloping by climbing a fence and Resident #33 being unsupervised during verbal abuse incidents, placing them at risk for altercations.
Failure to provide adequate supervision and monitoring to prevent altercations between residents, specifically between Resident #33 and Resident #214 resulting in injury requiring hospital treatment.
Unsafe and uncomfortable environment due to mismatched paint and damaged desk at the Unit 2 nursing station.
Report Facts
Residents sampled: 16
Residents affected by discharge planning deficiency: 1
Residents affected by supervision deficiency: 2
Residents affected by environmental deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Substance Abuse Counselor #1 | Substance Abuse Counselor | Responded to Code Grey altercation between Resident #33 and Resident #214 |
| Registered Nurse #1 | Registered Nurse | Responded to main dining room altercation between Resident #33 and Resident #214 |
| Associate Administrator | Associate Administrator | Interviewed regarding Resident #33's discharge planning and altercation supervision |
| Director of Nursing Service | Director of Nursing Service | Interviewed regarding discharge barriers and altercation investigation |
| Director of Recreation | Director of Recreation | Interviewed about supervision during smoke breaks and elopement incident |
| Recreation Leader/Smoke Monitor | Recreation Leader/Smoke Monitor | Responsible for supervising residents on patio during elopement incident |
| Facilities Director | Facilities Director | Interviewed about fence damage and facility maintenance |
| Registered Nurse #3 | Registered Nurse | Interviewed about maintenance work order for nursing station repairs |
| Maintenance Worker #1 | Maintenance Worker | Interviewed about maintenance rounds and repair issues |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Dec 22, 2023
Visit Reason
Inspection identified 9 standard health citations and 4 life safety code citations, all Level 2 severity, related to environment, safety, and care processes. All deficiencies were corrected by February 15, 2024.
Findings
Inspection identified 9 standard health citations and 4 life safety code citations, all Level 2 severity, related to environment, safety, and care processes. All deficiencies were corrected by February 15, 2024.
Deficiencies (13)
Corridors have firmly secured handrails
Discharge planning process
Dispose garbage and refuse properly
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Nutritive value/appear, palatable/prefer temp
Provide/obtain specialized rehab services
Safe/clean/comfortable/homelike environment
Safe/functional/sanitary/comfortable environ
Electrical equipment - power cords and extens
Smoke detection
Smoking regulations
Vertical openings - enclosure
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Dec 4, 2023
Visit Reason
The inspection was conducted as an Abbreviated Survey to investigate an alleged abuse incident involving Resident #1, reported by a Recreational Aide who observed a Certified Nurse Assistant allegedly hitting the resident and cursing at them during care.
Complaint Details
The visit was complaint-related, triggered by an allegation reported on 09/12/2023 that CNA #1 hit Resident #1 in the face with a towel and cursed at them. The allegation was not reported to NYSDOH as required. The facility investigation found no evidence of abuse, with conflicting witness statements and no visible injury. Resident #1 was unable or unwilling to provide details. The complaint was not substantiated due to lack of evidence.
Findings
The facility failed to report the alleged abuse to the New York State Department of Health within the required two-hour timeframe. The investigation found conflicting accounts, no visible injury on Resident #1, and no documented nurse assessment after the allegation. Additionally, the facility did not maintain accurate clinical records regarding the incident.
Deficiencies (2)
Failure to timely report suspected abuse to the appropriate authorities as required by facility policy and state regulations.
Failure to maintain clinical records that were completed and accurately documented, including lack of documentation of nurse assessment after abuse allegation.
Report Facts
Date of alleged incident: Sep 12, 2023
Date of survey completion: Dec 4, 2023
Number of residents sampled for abuse: 3
Number of residents affected: 1
Suspension duration: 1
Suspension duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Assistant | Named in abuse allegation and investigation |
| RA #1 | Recreational Aide | Reported the alleged abuse incident |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding incident handling and reporting |
| Administrator | Facility Administrator | Interviewed regarding incident investigation and reporting |
| RNS #1 | Registered Nurse Supervisor | Assessed Resident #1 but did not document assessment |
| Director of Recreation | Director of Recreation (DOR) | Reported noises and alleged abuse observation |
| Medical Doctor | Medical Doctor (MD) | Evaluated Resident #1 with no visible injury noted |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Involved in assessment and documentation instructions |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Dec 4, 2023
Visit Reason
Inspection identified 2 standard health citations related to reporting of alleged violations and resident records confidentiality, both Level 2 severity and corrected by January 15, 2024.
Findings
Inspection identified 2 standard health citations related to reporting of alleged violations and resident records confidentiality, both Level 2 severity and corrected by January 15, 2024.
Deficiencies (2)
Reporting of alleged violations
Resident records - identifiable information
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Nov 3, 2021
Visit Reason
Inspection identified 2 standard health citations related to comprehensive care plan and accident hazards, both Level 2 severity and corrected by January 12, 2022.
Findings
Inspection identified 2 standard health citations related to comprehensive care plan and accident hazards, both Level 2 severity and corrected by January 12, 2022.
Deficiencies (2)
Develop/implement comprehensive care plan
Free of accident hazards/supervision/devices
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Oct 8, 2021
Visit Reason
The inspection was conducted as a recertification survey with complaint investigation to assess compliance with regulatory standards related to housekeeping, care planning, medication administration, infection control, staffing, and food safety.
Complaint Details
The complaint investigation revealed multiple deficiencies related to housekeeping, care planning, medication administration, infection control, staffing shortages, and food safety practices.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, developing and implementing comprehensive care plans, providing care and supervision for self-administration of tube feeding and respiratory care, ensuring proper care of IV PICC lines, maintaining adequate nursing staff, and following infection prevention and control protocols including proper cleaning and labeling of oxygen and suction tubing. Additionally, food equipment such as the meat slicer was not properly cleaned or covered.
Deficiencies (7)
Failure to maintain a safe, clean, comfortable, and homelike environment with housekeeping deficiencies including dirty floors, peeling walls, and rusty tables.
Failure to develop and implement a complete, person-centered comprehensive care plan for resident's self-care administration of tube feeding and respiratory care.
Failure to provide care and supervision for self-administration of tube feeding and respiratory care, with lack of documentation and monitoring.
Failure to ensure proper care and maintenance of IV PICC line including failure to change dressing as ordered and lack of documentation.
Insufficient nursing staff to meet resident needs, resulting in missed doses of intravenous antibiotics during night shifts.
Failure to maintain meat slicer in a clean and sanitary manner; slicer was uncovered and electric cord improperly wrapped for multiple days.
Failure to implement infection prevention and control practices including failure to change and label oxygen and suction tubing as required, and improper handling of suction equipment.
Report Facts
Missed antibiotic doses: 7
Staffing ratios: 1
Suction container volume: 550
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding resident self-administration of tube feeding and respiratory care. |
| RN #1 | Nursing Supervisor | Interviewed regarding care plan oversight and supervision of resident self-care. |
| RN #2 | Registered Nurse | Observed administering IV medications and interviewed about PICC line care. |
| Staff #4 | Infection Prevention and Control Program Staff | Interviewed regarding infection control practices and compliance monitoring. |
| Staff #5 | Dietician | Interviewed regarding food safety and resident nutritional status. |
| Staff #6 | Dietary Director | Interviewed regarding meat slicer cleaning and food safety policies. |
| Staff #7 | Kitchen Cook | Interviewed regarding meat slicer cleaning and storage practices. |
| DON | Director of Nursing | Interviewed regarding nursing supervision, infection control, and care plan compliance. |
| Administrator | Facility Administrator | Interviewed regarding overall facility compliance and corrective actions. |
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